Community stakeholder‐driven technology solutions towards rural health equity: A concept mapping study in Western Canada

Abstract Background Technology holds great potential for promoting health equity for rural populations, who have more chronic illnesses than their urban counterparts but less access to services. Yet, more participatory research approaches are needed to gather community‐driven health technology solutions. The purpose was to collaboratively identify and prioritize action strategies for using technology to promote rural health equity through community stakeholder engagement. Methods Concept mapping, a quantitative statistical technique, embedded within a qualitative approach, was used to identify and integrate technological solutions towards rural health equity from community stakeholders in three steps: (1) idea generation; (2) sorting and rating feasibility/importance and (3) group interpretation. Purposeful recruitment strategies were used to recruit key stakeholders and organizational representatives from targeted rural communities. Results Overall, 34 rural community stakeholders from western Canada (76% female, mean age = 55.4 years) participated in the concept mapping process. In Step 1, 84 ideas were generated that were reduced to a pool of 30. Multidimensional scaling and cluster analysis resulted in a six‐cluster map representing how technological solutions can contribute toward rural health equity. The clusters of ideas included technological solutions and applications, but also ideas to make health care more accessible regardless of location, training and support in the use of technology, ensuring digital tools are simplified for ease of use, technologies to support collaboration among healthcare professionals and ideas for overcoming challenges to data sharing across health systems/networks. Each cluster included ideas that were rated as equally important and feasible. Key themes included organizational and individual‐level solutions and connecting patients to newly developed technologies. Conclusions Overall, the grouping of solutions revealed that technological applications require not only access but also support and collaboration. Concept mapping is a tool that can engage rural community stakeholders in the identification of technological solutions for promoting rural health equity. Patient or Public Contribution Rural community stakeholders were involved in the generation and interpretation of technological solutions towards rural health equity in a three‐step process: (1) individual brainstorming of ideas, (2) sorting and rating all ideas generated and (3) collective interpretation and group consensus on final results.


| BACKGROUND
Health inequities are systemic and avoidable differences in health that are caused by the unfair distribution of resources, wealth and power in society. 1 People who experience systemic disadvantages (e.g., due to racism, exclusion, impacts of colonization, socioeconomic status or access to services) also experience greater burdens of health inequities. 2,3 Social and structural determinants of health that contribute to rural health inequities include financial, social and geographical difficulties such as travel to access care; reduced access to healthcare professionals; lack of healthcare facilities, services and equipment; inadequate infrastructure and lack of rural-specific programmes. 4,5 In western Canada, dispersed rural and remote community settings accentuate the drivers of ill health and limit access to health care. 5,6 Chronic diseases such as cardiovascular disease, asthma and diabetes along with poor mental health, obesity, lower life expectancy and potentially avoidable mortality are higher in rural and remote areas than in urban areas of Canada. 7 Living with chronic illness can increase healthcare needs which can exacerbate the drivers of health inequity. One possible solution for reducing health inequities is the use of technology to promote inclusive health and social care for disadvantaged rural populations. Research examining the ways technology solutions can best integrate rural needs, values and strengths can therefore be an important contributor to advancing rural health equity.
Digital health technologies are revolutionizing health and social care, opening new possibilities for increasing access, reducing inequities and promoting equity. For example, mobile technologies such as mobile phone apps hold considerable potential to reduce inequities because of their extensive use across all social groups. 8 Remote monitoring and synchronous video-based technologies offer opportunities to develop community-based interventions and reduce the need for proximity or travel to healthcare providers. 9 Virtual care (including telehealth), defined as any remote interaction between patients and their circle of care using communication/ information technology, 10 rapidly expanded to rural and remote communities during the COVID-19 pandemic to provide services previously unavailable. 11,12 Although digital access is far from equal across geographic contexts, and many rural communities lack a digital infrastructure, 13 high-speed internet to 200 rural and Indigenous communities, enhancing opportunities for harnessing technological solutions for more equitable access to health-related resources, information and services. 15,16 This expanded infrastructure creates opportunities to move beyond urban contexts to customize technological solutions to rural locales.
Yet, geographical place shapes how technology is used or not used, 17 and the rural context is diverse and an especially important consideration with the expedited need for technology across jurisdictions as a result of COVID-19. Participatory communitydriven research is ideally suited to identify acceptable and relevant user-driven solutions to pragmatic real-life issues. 18,19 Communityengaged research is a people-centred approach building from community strengths and priorities. It is crucial to promoting health equity by integrating diverse voices including those of marginalized groups 20, 21 and aligned with the direction of this study. Involving communities as partners in the research process reduces the power differential that often characterizes a top-down approach and enhances the planning, conduct and usability of the research. 22,23 Engaging rural community stakeholders in the co-identification and co-creation of community-centred solutions also facilitate integrated knowledge translation. 24 In the current study, a knowledge-to-action technique, known as concept mapping, was used to engage rural community stakeholders, giving them an active voice in generating solutions and bringing their community, experiential, professional and tacit knowledge into shaping a collective understanding of how technology relates to rural health equity. The research question guiding the study was: What are priority technology solutions to support the health and well-being of people living with chronic illness in rural communities? 2 | METHODS

| Study design
A concept mapping approach was used to generate and compile technology solutions for rural community members living with chronic illness. Concept mapping is well suited to identify future strategic planning and evaluation 25,26 and to explore lived experience in participatory public health research. 18 Concept mapping allows for both individual brainstorming of ideas as well as mapping complex concepts to reveal an underlying structure not directly identified by individual participants. 27,28 The concept mapping approach used in this study was informed by the work of Trochim 26

| Study setting and recruitment
This study was conducted in a western region of Canada that is characterized by substantial geographic differences in urban and rural characteristics, with over 40% of the population living outside two major metropolitan areas. 29 The geography is diverse (e.g., forests, lakes, deserts, grass plains) and 75% of the region is covered by mountains. 30 In contrast to urban areas, demographic ageing data indicate a larger proportion of older adults in rural communities. 31 Ten rural communities (populations ranging from 957 to just over 10,000) were targeted in the interior region of the province (where medical services were provided through one of the provincial health regions) to leverage research team connections. The rural communities varied with respect to Statistics Canada's Index of Remoteness (based on population and travel to the nearest population centre) as five communities were classified as 'less accessible areas', and five were 'remote areas'. 32

| Data collection
Polygon Research Inc., a Canadian company based in Quebec, provided the concept mapping platform, Insight Forming, 34 which was used to facilitate the collection, processing and visualization of data. Participants were sent a link to the secure platform, where they entered an email address to create an account and 'login' to the study to complete the online questionnaire and consent forms. The online, asynchronous concept mapping process allowed us to reach a broad group of stakeholders, circumventing geographical limitations, though one participant completed a paper version that was entered by the research staff. In the present study, our goal was to collaborate with our community partners in mapping the final solution; thus, we also organized a virtual group discussion session for participants to co-interpret a visual solution. The online concept mapping process included three steps: Step 1: Generate Statements; Step 2a: Sort Statements; Step 2b: Importance and Feasibility Rating; Step 3: Consensus Discussion (see Figure 1 for a flow diagram of the concept mapping process and timeline). All participants were also asked to complete a short (5 min) demographic questionnaire. This included age; gender, marital status, sector/affiliation (e.g., health/ social services, nonprofit/charitable organization, education, policy/ government); education level; ethnicity; status as living with, or caring for someone with, chronic illness; access to the internet at home; adequacy of internet access (reliability/quality) on a scale ranging from poor (1) to excellent (10) and community name. Participants were provided with a $10 eGift card for participating in Step 1, a $20 eGift card for participating in Step 2 and a $50 eGift card for participating in Step 3.

| Step 1: Generate Statements
In Step 1, participants completed an idea generation activity between 14 July and 3 September 2020 (7 weeks) in response to the question: 'What are possible technology solutions that could address the health and well-being issues of people living with chronic illness in rural BC communities?' The number of responses participants could generate was not limited in this first step. Once enough stakeholders had completed the first step to start seeing saturation in the responses, complex responses were broken down by two study authors (C. L. S. and P. R.) into individual ideas, duplicate responses were collapsed, language was simplified to ensure understanding and ultimately responses reflecting similar content were synthesized into global statements.

| Step 2a: Sort Statements
In Step 2a, participants were invited to individually sort the final pool of synthesized statements generated by all participants into groups of conceptually similar ideas and provide names for these groups over a 3-week period (10-30 October 2020). Instructions told participants: 'In this step you are being asked to sort the items into groups. You can sort in whatever way makes sense to you, and give your groups any name you would like. Please try to sort all items; however, each group you create needs to contain at least 2 items'. Participants could create as many groups to represent the statements as they saw fit.

| Step 2b: Importance and Feasibility Rating
Simultaneously, in Step 2b, participants rated each of the synthesized statements in terms of importance and feasibility. Participants were asked to rate as they felt best: 'What level of importance do you consider this statement?' (from 1 = not important at all to 6 = very important) and 'What would be the feasibility of this solution for rural BC communities?' (from 1 = very low to 6 = very high).

| Step 3: Group Consensus Discussion
In Step 3, a 2-h virtual discussion session (4 November 2020) was held using Zoom where the clusters were presented visually and participants discussed the individual solutions in each cluster and their association. Options for cluster names (based on names participants had given groups when sorting) were presented in a poll to participants. The top choices for names were discussed and often modified from what was originally presented in the poll. After clusters were named, participants were asked in another poll: 'Which cluster is your top priority for action'. Finally, participants were asked to discuss the overall organization of the clusters of ideas and to collectively identify the conceptual regions or 'bigger picture' that could be present in the map of solutions.

| Data analysis
Hierarchical cluster analysis and nonmetric multidimensional scaling (nMDS) were used to merge the sorted items into a combined set of clusters. 35 The concept map visually represented these concepts in two-dimensional space. A Kruskal stress index was computed to assess the goodness of fit. 36 Two hierarchical clustering methods, the unweighted pair-group method using arithmetic averages (UPGMA) and Ward's 2 minimum variance clustering, were compared to assess the reliability of the Descriptive statistics were used to summarize the demographic data in SPSS version 27. 41 Mean ratings of feasibility and importance for each technological solution were generated by taking the average of all participant ratings. Then a scatterplot of mean ratings of importance and feasibility was used to generate a 'go-zone'. In concept mapping, a 'go-zone' graph is used to identify items that are rated both highly important and highly feasible. 28 A ranking of average ratings (means) was used to determine cutoff points for the 'go-zone'.
The group consensus discussion was audio-recorded and transcribed. Using a content analysis approach, 42 participants' interpretations of the clusters and main areas of consensus were identified, and representative quotes were selected to illustrate participants' perceptions.

| Participants and sample characteristics
A total of 34 people (26 females, 7 males and 1 preferred not to answer) participated in this concept mapping process. Most participants (n = 30; 88.2%) identified as residents of rural communities in the study region, and 4 (11.8%) were stakeholders with technology or rural health backgrounds from larger urban centres.
There were one to seven participants from each community (median = 3). All 34 (100%) participants reported having access to the internet at home, and adequacy of internet access (reliability/ quality) was rated good/excellent (7, 8, 9 or Table 1). In Step 2, 16 participants (56% female; 87.5% rural; M age = 59 years; 81% married; 81% University degree; 75% Caucasian) returned and sorted the ideas into groups and then rated items in terms of their importance and feasibility.

| Generating a concept map
Using hierarchical cluster analysis and nMDS, the items of individual participants sorted into groups were combined into a set of six clusters. Table 1 presents the abbreviated statements organized by cluster, along with average ratings of importance and feasibility. The  family, friends and support groups to reduce isolation and loneliness' was removed because it had a low internal validity for the clustering solutions, meaning most participants sorted it into differing groups.
The UPGMA and Ward's clustering methods provided highly similar results on all indices suggesting the six-cluster solution was reliable. Ultimately, the UPGMA method was selected, as some indices (e.g., cluster stability) were slightly higher than using Ward's clustering. Using the UPGMA method, average Jaccard similarities between bootstrapped pairwise clustering solutions for the six clusters ranged from 0.61 to 0.82, suggesting at least somewhat valid, stable clusters when resampling the data. Figure 3 presents a concept map of the 27 statements with a six-cluster solution.

| DISCUSSION
The purpose of this study was to collaboratively identify and prioritize action strategies for using technology to promote rural health equity.
With the engagement of diverse rural community stakeholders, the findings present a co-created set of technology solutions to support the health and well-being of people living with chronic illness in rural communities. Although the study results are based on experiences in rural settings in western Canada, the findings may also hold value for other rural contexts where similar factors influence health inequities.